前列腺癌根治术后Gleason评分升级与术前多参数MRI PI-RADS评分的关系

目的探讨前列腺癌根治术后Gleason评分升级与术前多参数MRI(mpMRI)前列腺影像报告数据系统(PIRADS)评分的关系。方法回顾性分析198例前列腺癌根治术后患者的资料。根据PI-RADS评分分为低分(1~2分),中分(3分),高分(≥4分)3组。通过单因素和多因素Logistic回归分析探讨PI-RADS评分与Gleason评分的关系。结果单因素分析显示,前列腺特异性抗原密度、前列腺体积、术前穿刺病理Gleason评分、精囊侵犯、穿刺阳性针数、PI-RADS评分是术后Gleason评分升级的影响因子(P均0.05)。多因素分析显示,前列腺体积(P0.01)与术前PI-RADS评分(P0.01)是前列腺癌根治术后Gleason评分升级的独立预测因素。术前PI-RADS评分低分组及中分组术前与术后Gleason评分差异无统计学意义(P均0.05);而高分组术后Gleason评分高于术前,差异有统计学意义(P0.05)。结论术前Gleason评分较低(≤6分)而PI-RADS评分较高(≥4分)的小体积前列腺癌患者,术后Gleason评分升级的可能大。     

Patient risk stratification using Gleason score concordance and upgrading among men with prostate biopsy Gleason score 6 or 7

PurposeTo define the impact of discordant Gleason sum (GS) between prostate biopsy (Pbx) tissue and radical prostatectomy (RP) specimen among men initially diagnosed with Gleason 6 or 7 prostate adenocarcinoma.Materials and methodsWe evaluated patients diagnosed with GS 6 or 7 and treated primarily with RP. We defined the frequency of GS discordance between Pbx and RP pathology reports. We analyzed pretreatment parameters associated with GS discordance and compared immediate postprostatectomy outcome variables across patient groups defined by their GS and concordance. We then conducted survival analysis for biochemical recurrence across patient groups defined by their GS and concordance status.ResultsAmong patients with GS 6 on Pbx, 681/1,847 (36.86%) patients were upgraded to GS 7 or higher after RP. Surgical margin, capsular involvement, seminal vesicle, and nodal involvement status were more favorable in patients with concordant Pbx and RP specimen with GS 6 (P < 0.0001). Patients with smaller transrectal ultrasound (TRUS) prostate volume were found to have higher PSA densities and were more likely to be upgraded at RP. Multivariate survival analysis also predicted fewer biochemical recurrence events over time in men with concordant Pbx tissue and RP specimen of GS 6 vs. 6/7 or 7/7 (P = 0.0025) controlling for other relevant covariates.ConclusionsGS discordance between Pbx tissue and RP specimens among prostate cancer patients initially diagnosed with either GS 6 or 7 adenocarcinoma of the prostate is substantial. This discordance has potential clinical significance in predicting oncologic outcomes.     

ISUP版Gleason评分在前列腺癌根治术后评分升级的影响因素分析

目的:探讨前列腺癌根治术后标本较前列腺穿刺活检标本Gleason评分升级的影响因素。方法:回顾性分析2012年1月至2015年6月接受前列腺穿刺活检确诊为前列腺癌并行根治性切除的235例患者年龄、术前PSA、前列腺体积、PSA密度(PSAD)、穿刺至手术间隔时间、穿刺阳性针数、切缘情况、精囊侵犯、淋巴转移等指标,统计其穿刺和术后Gleason评分的差异。运用Logistic回归分析引起术后Gleason评分升级的危险因素。结果:164例患者纳入分析,其中术前穿刺与根治术后标本Gleason评分相符有95例(57.93%),术后上升55例(33.54%),下降14例(8.52%)。前列腺体积(P0.01)和穿刺评分(P0.05)是影响根治术后标本Gleason评分升级的独立预测因子,其中前列腺体积≤25 ml组其术后Gleason评分升高的风险是体积60 ml组的27倍(P0.05),前列腺体积25~40 ml组术后Gleason评分升高的风险是体积60 ml组的9倍(P0.05)。结论:穿刺Gleason评分≤6、小体积前列腺(≤40 ml),术后Gleason评分升级可能性大。     

Smaller prostate gland size and older age predict Gleason score upgrading

ObjectivesGleason score is important for prostate cancer (CaP) risk stratification and prognostication but has a significant rate of upgrading. We examined the effect of prostate size and age on upgrading of Gleason 6 CaP.Materials and methodsA retrospective review was performed of patients with Gleason 6 CaP who underwent radical prostatectomy from 2001 through 2010. Preoperative clinical and pathologic variables were assessed to determine association with risk of upgrading at prostatectomy.ResultsA total of 1,836 patients were identified with Gleason 6 on prostate biopsy. Upgrading was observed in 543 (29.6%) patients with a final Gleason score of 3+4 in 463 (25.2%), 4+3 in 49 (2.7%), and 8–10 in 31 (1.7%). On univariate logistic regression, age, prostate weight, and PSA were significant predictors of Gleason score upgrading and remained significant on multiple logistic regression. Prostate weight was inversely related to risk of upgrading. To further explore this effect, we performed multiple logistic regression to examine risk of Gleason 6, 7, or 8–10 disease in 2,493 patients with Gleason 6–10 at prostatectomy. After controlling for age and PSA, there was a progressively increased risk of Gleason 6, 7, and 8–10 disease with decreasing prostate weight.ConclusionsOlder age, higher PSA, and smaller prostate gland size are associated with increased risk of Gleason score upgrading. The inverse relationship of prostate weight to risk of Gleason upgrading may be related to increased high-grade disease in smaller glands.     

Predictors for clinically relevant Gleason score upgrade in patients undergoing radical prostatectomy

Study Type – Diagnostic (exploratory cohort) Level of Evidence 2b What’s known on the subject? and What does the study add? Clinically relevant GSU in the prostatectomy specimen is a common phenomenon. Clinically relevant GSU occurs in one of three patients with clinically ‘very’ low‐risk PCa, and a low number of biopsy cores is the key negative predictor.

OBJECTIVE

? To evaluate clinical predictors for Gleason score upgrade (GSU) in radical prostatectomy (RP) specimen, especially in patients with ‘very’ low risk PCA (T1c and biopsy Gleason score ≤6 and PSA <10 ng/ml and ≤2 positive biopsy cores and PSA density <0.15).

Patients and Methods

? 402 consecutive patients undergoing RP between 2004 and 2006, including a subgroup of 62 patients with ‘very’ low risk PCA, were examined. ? Patients were categorized for clinically relevant GSU (defined as upgrade into a higher PCA risk category). ? Parameters including number of biopsy cores obtained, positive biopsy cores, prostate weight, PSA, DRE and pathology department were evaluated for their role as predictors. ? Furthermore, GSU in RP specimen was analyzed for its impact on pT‐stage.

RESULTS

? Clinically relevant GSU occurred in 38.1% in the whole cohort and in 32.3% in the ‘very’ low risk PCA subgroup. Gleason score downgrade (GSD) occurred in 4.7%. ? Number of biopsy cores obtained and prostate weight were independent negative predictors of GSU in all 402 patients (P = 0.02 and P = 0.03, respectively). ? In the ‘very’ low risk group, only number of biopsy cores obtained revealed as an independent negative predictor of GSU (P = 0.02). ? PSA, DRE, number of positive cores or pathology department were not associated to GSU. ? In the ‘very’ low risk group, GSU was related with extracapsular tumor extension (P = 0.05).

Conclusions

? Clinically relevant GSU in RP specimen is still a challenging problem. ? Increasing the number of biopsy cores lower this risk significantly. GSD is rare and thus of minor importance for treatment decisions.     

The probability of Gleason score upgrading between biopsy and radical prostatectomy can be accurately predicted

The objective of this study was to test the external validity of a previously developed nomogram for the prediction of Gleason score upgrading (GSU) between biopsy and radical prostatectomy (RP). The study population consisted of 973 assessable patients treated with RP at a tertiary care institution. The accuracy of the nomogram was quantified with the receiver operating characteristics curve-derived area under the curve. The performance characteristics (predicted vs observed rate of GSU) were tested within a calibration plot. Overall, GSU was recorded in 39.8% ( n  = 387) of patients at RP. Of patients with GSU, 70 (18.1%), 23 (5.9%) and 32 (8.3%), respectively, had extracapsular extension, seminal vesicle invasion and lymph node invasion. The accuracy of the nomogram was 74.9% (confidence interval 72.1–77.6%). The model tended to underestimate the observed rate of GSU and the discordance between the predicted and observed rate of GSU ranged from −7 to +10%. The current tool represents the most accurate method of predicting GSU between biopsy and RP. Nonetheless it is not perfect and its performance characteristics should be known prior to its use in clinical decision-making.     

建立矫正体系提高前列腺癌患者手术前后Gleason评分符合率

目的建立提高前列腺癌患者穿刺Gleason评分与术后Gleason评分符合率的矫正体系。方法系统性回顾2014年9月至2018年9月在南京医科大学第一附属医院及江南大学附属医院行经直肠超声引导下前列腺活检、诊断为前列腺癌并行前列腺癌根治术的患者,分为符合组和不符合组,联合相关参数及统计学方法,建立穿刺Gleason评分矫正体系。比较两组应用矫正体系前后总体符合率、诊断效率及不同Gleason评分间的变化情况。结果Gleason评分矫正体系显著提高了穿刺Gleason评分与术后Gleason评分的符合率(60.3%vs.50.2%,P=0.002),相比于传统的临床指标如前列腺特异性抗原(0.533)、针数体积比(0.517),评估模型的受试者工作曲线下面积明显升高(0.641),诊断效率更高。矫正体系应用前后Gleason评分7分患者符合率有显著提高,且与6分患者符合率变化间差异有统计学意义(P<0.001)。结论本研究建立了针对提高前列腺癌患者手术前后Gleason评分符合率的矫正体系,对于临床医师采取精准治疗有着重要的参考价值。     

Increasing the number of biopsy cores improves the concordance of biopsy Gleason score to prostatectomy Gleason score

OBJECTIVE: To evaluate taking more biopsy cores for predicting the radical prostatectomy (RP) Gleason score compared with the biopsy Gleason score, as although random sextant biopsies are the standard for a tissue diagnosis of prostate cancer, and taking more biopsies increases the detection rate, it is uncertain whether taking more cores improves the prediction of the RP Gleason score. PATIENTS AND METHODS: We analysed retrospectively 404 patients from three centres (Seattle 162, Washington 107 and Chicago 135) who had RP for prostate cancer. Six, eight or 10 biopsies were taken based on the physician's preference and the patient's characteristics. RESULTS: Before RP, 158 (39%) patients had six, 65 (16%) had eight and 181 (45%) had 10 biopsy cores taken. The accuracy of the Gleason sum of the three groups was 65/158 (41%), 26/65 (40%) and 104/181 (57.5%), respectively (P < 0.004, 10-core vs six-core). However, when comparing the Gleason score separately (i.e. 4 + 3 is not equal to 3 + 4), the accuracy of the three groups was 48/158 (30%), 20/65 (31%), and 95/181 (52.5%), respectively (P < 0.001, 10-core vs six core). CONCLUSIONS: Taking more biopsy cores improves the accuracy of the biopsy Gleason score in predicting the final Gleason score at RP; the predictive accuracy of the final Gleason score may be increased from 41% to 58% by increasing the number of biopsies from six to 10.     

The influence of ethnicity on Gleason score

BackgroundTo determine if Gleason score exhibits any significant variation between African-Americans and Caucasian men with prostate cancer.MethodsWe conducted a retrospective cohort study. Inclusion required diagnosis of prostate cancer and reporting it to the TriHealth tumor registry from 1995–2005. We excluded individuals of any other ethnicity than the two of interest (N = 15) and individuals without a reported Gleason score (N = 82). For each patient we collected data on ethnicity, Gleason score, age, American Joint Committee on Cancer (AJCC) stage, insurance status, and surgery. Gleason score was divided into low-grade (1–6) and high-grade disease (7–10). Institutional Review Board approval was obtained prior to data collection.ResultsA total of 1916 patients, (1476 Caucasians, 440 African-Americans) were eligible for inclusion in the study. There was no significance difference between either ethnicity for age, insurance status, and the percentage of men needing a transurethral resection of the prostate (TURP). There was no difference between either ethnicity for stages 0, 1, and 4. African-Americans were more likely to have stage 2 disease, while Caucasian men possessed more stage 3 disease (p<0.05). African-Americans were significantly more likely to not have any prostate surgery (p<0.05). Caucasian men were more likely to have a prostatectomy. African-American men with prostate cancer were significantly more likely to have a high-grade Gleason score compared to Caucasian men (OR = 1.22, 95% CI = 1.11–1.35).ConclusionAfrican-American race is a predictor of more advanced Gleason score at the time diagnosis of prostate cancer.     

Prognostic value of the Gleason score in prostate cancer

OBJECTIVE: To investigate the prognostic value of the Gleason score in prostate cancer. PATIENTS AND METHODS: A consecutive series of 305 men with prostate cancer diagnosed at transurethral resection (1975-1990) and with no curative treatment was analysed. There was no assessment of prostate-specific antigen level during this period. The mean (range) age at diagnosis was 73.7 (52-95) years and the mean follow-up was 6.4 (0-22) years. The influence of Gleason score and the percentage of the specimen area with tumour (% cancer) on disease-specific survival were assessed using Kaplan-Meier analyses. RESULTS: Of 305 cancers, 22% had a Gleason score of 4-5, 29% of 6, 18% of 7 and 32% of 8-10. At the follow-up, 89% of the men had died, of whom 42% had died from prostate cancer. The disease-specific 10-year survival was 56%. The disease-specific mean survival (DSMS) for Gleason score 4-5, 6, 7 and 8-10 was 20, 16, 10 and 5 years, respectively (P < 0.001). The DSMS did not differ significantly between Gleason 4 and 5 or between 8-10. There was a trend towards shorter survival for Gleason 4 + 3=7 (DSMS 9 years) than GS 3 + 4=7 (DSMS 13 years; P = 0.16). Gleason score and % cancer were independent predictors of DSMS (P < 0.001). CONCLUSION: The long-term prognosis of prostate cancer on deferred treatment is predicted well by the Gleason score. Four prognostic categories of prostate cancer are suggested, i.e. Gleason score 4-5, 6, 7 and 8-10.